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GI block 2 > Lecture 1 - Large Intestine > Flashcards

Lecture 1 - Large Intestine Flashcards

1
Q

Antibiotic associated diarrhea is not the same as antibiotic associated colitis.

True colitis is nearly always a result of infection with c. diff.

If a patient comes in w/ diarrhea OR gets diarrhea in the first 2 days, we typically don’t consider C diff.

A

Remember, diarrhea acquired on day three or after, we should consider C diff.

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2
Q

Fluoroquinolones
Ampicillin
Clindamycin
Cephalosporins (3rd gen)

A

Most common causative agents of C diff

however, almost all have been implicated

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3
Q

Watery, greenish, foul smelling stool that may contain mucus

Abd cramping

Mild leukocytosis on CBC (<15,000)

A

Mild-moderate antibiotic associated colitis

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4
Q

Profuse diarrhea and fever (<101.3)

Hypoalbuminemia (serum albumin < 3g)

PLUS 1 of:

Abd pain w/ diffuse TTP

OR

leukocytosis on CBC >15,000

A

Severe disease

Antibiotic associated colitis

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5
Q

What are the reqs for a SEVERE version of antiobiotic associated colitis?

A
  1. Profuse diarrhea/fever (<101.3)
  2. Hypoalbuminemia (<3g/dL)

AND at least one of the following…

3a. Abd pain w/ diffuse TTP
3b. Leukocytosis on CBC > 15000

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6
Q 
Admission to ICU
HOTN (w/ or w/o vasopressors)
Fever > 101.3
Ileus of significant/visible abd distension
Mental status changes
WBC>35,000
Serum > 2.2
End organ failure
A

FULMINANT antibiotic associated colitis

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7
Q

Result of severe inflammation

Manifests as raised yellow or off-white plaques up to 2 cm in diameter

A

Pseudomembranous colitis

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8
Q

Study of choice for Antibiotic associated colitis?

What’s another option?

A

PCR = study of choice

Another option is Enzyme Immunoassay (EIA), which requires two samples

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9
Q

For antiobiotic associated colitis, when is imaging warranted? What are we evaluating for?

A

When there’s evidence of fulminant disease. Used to evaluate for toxic megacolon, perforation, or other complications

contrast enhanced CT

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10
Q

What are some complications of fulminant antibiotic associated colitis?

A 
Hemodynamic instability
Hypercoagulability (from hypoalbuminemia(
Respiratory failure
Metabolic acidosis
Toxic megacolon
Bowel perf
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11
Q

What are general tx measures for antibiotic associated colitis (regardless of severity)?

A

Admission
***D/c offending antibiotic!
Infection control measures
Correct fluid/electrolyte disturbances

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12
Q

First line tx for MILD/MODERATE antibiotic associated colitis?

A

Metronidazole 500 mg PO TID x 10 days

alternate = vancomycin 125 mg PO QID x 10 days

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13
Q

What would you do if there’s no clinical improvement w/ metronidazole therapyin 5-7 days?

A

Switch to vancomycin

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14
Q

Why not just start w/ vancomycin?

A

COST and decrease in likelihood of abx resistance

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15
Q

Tx for SEVERE antibiotic associated colitis?

A

Vancomycin 125 mg PO QID x 10 days

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16
Q

Tx for FULMINANT antibiotic associated colitis?

A

Vancomycin 500 mg PO QID

AND

Metronidazole 500 mg IV q8 hrs

AND

Vancomycin PR 500 mg QID

AND EARLY CONSULTATION

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17
Q

A quarter of patients w/ abx associated colitis will relapse w/ 14 days…

What’s the tx for the FIRST relapse?

A

Repeat course of abx

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18
Q

What’s the tx for a subsequent relapse (i.e., third case) of antibiotic associated colitis?

A

7 WEEK taper of vancomycin

Consider probiotics/fecal transplant

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19
Q

Total or segmental colonic dilatation

Non obstructive

LARGER THAN 6 CM (must be assessed by rad)

Systemic toxicity

A

Toxic megacolon

complication of IBD but typically ulcerative colitis

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20
Q

Radiographic evidence of colonic distension (>6cm)

PLUS 3 of:

2a. Fever (100.4)
2b. Pulse (>120)
2c. Leukocytosis (>10,500)
2d. Anemia

PLUS 1 of:

3a. Dehydraion
3b. AMS
3c. Electrolyte abnormality
3d. HOTN

A

Toxic megacolon

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21
Q

Evidence req’d for toxic megacolon?

A

Radiographic evidence of colonic distension (>6cm)

PLUS 3 of:

2a. Fever (100.4)
2b. Pulse (>120)
2c. Leukocytosis (>10,500)
2d. Anemia

PLUS 1 of:

3a. Dehydraion
3b. AMS
3c. Electrolyte abnormality
3d. HOTN

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22
Q

Tx for toxic megacolon?

A

Reduce colonic distension

Correct fluid/electrolyte disturbances

Treat toxemia/precipitating factors

Surgical consult

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23
Q

Sac like protrusion of the colonic wall?

A

diverticulum

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24
Q

Most are asymptomatic (“incidental findings”)

Vary in size/number

Nearly universally present in sigmoid/descending colon

Pathogenesis related to increaed intraluminal pressure (low fiber/insufficient water intake)

A

Colonic diverticula

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25
Q

What is the diverticulosis?

Tx/work up?

A

Presence of diverticula (usually found incidentally/typically asymptomatic)

No specific tx or further work up is necessary (recommend increase in dietary fiber/water)

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26
Q

Diverticular bleeding is typically self-limited. However, pt may complain of what?

A

Painless hematochezia (blood that squirts into the toilet)

Typically no other ssx

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27
Q

Tx for diverticular bleeding?

A

With active bleeding, resuscitation/stabilization (CONSIDER UPPER GI BLEED) and endoscopy

Pts w/o active bleeding, refer for scope (colonoscopy)

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28
Q

Inflammation/perforation of a diverticulum (typically a micro-perforation and results in an intraabdominal infection). How’s the pt present?

A

Diverticulitis pt presents w/

abdominal pn/tenderness in LLQ

Fever

N/V

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29
Q

Diverticulitis PE?

Labs?

A

LLQ TTP (20% will have a mass)

Fever

Lab = leukocytosis (w/w/o +FOBT)

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30
Q

WHAT DO WE NOT GIVE A PT W/ DIVERTICULITIS?

A

NO ENDOSCOPY

31
Q

Diagnostic imaging for diverticulitis?

A

Abd CT

but not always necessary in pts w/ mild dz, ie, mild TTP w/ no fever

32
Q

Mild diverticulitis tx?

Type of abx?

A

Outpatient

Oral broad spectrum abx:
1. Metronidazole + Cipro

  1. Metronidazole + TMP-SMX
  2. Amoxicillin-Clavulanate

(7-10 days)

Clear liquid diet (advance as tolerated)

33
Q

What disease/condition?

Clear liquid diet

Oral broad spectrum abx:
1. Metronidazole + Cipro

  1. Metronidazole + TMP-SMX
  2. Amoxicillin-Clavulanate
A

Diverticulitis

34
Q

Criteria for INPATIENT mgmt of diverticulitis?

A

Complicated diverticulitis as seen on CT scan

Sepsis

High fever (>102)

Significant leukocytosis

Advanced age

Immunocompromise

Significant comorbidities

Unable to tolerate PO intake

Failure of outpatient mgmt

35
Q

Complicated diverticulitis as seen on CT scan

Sepsis

High fever (>102)

Significant leukocytosis

Advanced age

Immunocompromise

Significant comorbidities

Unable to tolerate PO intake

Failure of outpatient mgmt

A

Diverticulitis that warrants inpatient mgmt

36
Q

Severe/inpatient mgmt of diverticulitis?

A

NPO

IV broad-spectrum abx (Once inflammation is stabilized -> PO)

IV fluid/electrolytes

IV pn mgmt

Surgical consultation

37
Q

When would you transition from IV to PO abx in severe diverticulitis?

A

Once inflammation is stabilized

38
Q

Potential complications of diverticulitis?

A

Perforation
Abscess
Fistulization
Obstruction (from severe inflammation)

39
Q

If a pt w/ diverticulits fails to improve after an abx regimen, what should be considered and obtained?

A

Consider complications, such as an abscess

Obtain CT if suspecting a complication

40
Q

Ssx of obstruction w/o mechanical lesion?

Presence of bowel dilation on imaging

A

Acute colonic pseudo-obstruction (Ogilvie Syndrome)

41
Q

When does acute colonic pseudo-obstruction occur?

A

Shortly after surgery (“postsurgical”)

Post-trauma

Medical inpatients (e.g., respiratory failure, MI, CHF)

42
Q

Ssx of acute colonic pseudo obstruction?

A

Abd distension

Abd pn

Nausea/vomiting

Essentials of DX:

  • severe abdominal distention
  • Postoperative state or severe medical illness
  • precipitated by electrolyte imbalances /meds
  • Absent to mild abdominal pain; min tenderness
  • massive dilation of cecum or R colon
43
Q

What imaging might be used for ACPO?

??f/u to determine study of choice

A

Plain film shows colonic dilation (USUALLY confined to cecum/right hemicolon)

(CT can r/o mechanical obstruction if suspected due to malignancy, volvulus, or fecal impaction)

normal cecal size is 9 cm… cecal diameter greater than 10-12 cm is associated w/ increased risk of perforation!

44
Q

Torsion of a segment of the alimentary tract is called?

What can it lead to?

Most common site?

A

Volvulus can lead to obstruciton

MOST COMMON SITE IS SIGMOID (can occur anywhere)

45
Q

Insidious onset of progressive abd pn
Continuous/severe pn at presentation

Nausea

Abd distension

Vomiting

CONSTIPATION

A

Sigmoid volvulus

(ACPO aka Ogilvie is only absent to mild abdominal pain)

Toxic megacolon from IBD or C diff would have fever; dehydration, sig abdominal pain; leukocytosis; and diarrhea, which is often bloody (instead of constipation)

46
Q

PE of sigmoid volvulus?

A

Distended abd w/ tympany to percussion

TTP

(lab tests typically unremarkable)

47
Q

Imaging and tx for sigmoid volvulus?

A

Plain abd films

CT to r/o other etiologies

Tx is detorsion via flex sig

48
Q

Protuberance extending into the lumen of the colon, that’s typically asympomatic… but may lead to?

A

Polyp… may lead to

Bleeding

Tenesmus

Obstruction

49
Q

Two types of polyps?

A

Pedunculated (connected by thinner stalk)

Sessile

50
Q

Four types of polyps?

A
  1. Mucosal adenomatous
  2. Mucosal serrated
  3. mucosal non-neoplastic
  4. Submucosal lesions
51
Q

Most common polyp?

Description?

A

Adematous

Dysplastic by definition

May be tubular, villous, or tubulovillous

52
Q

Display a lumen w/ serrated or stellate architecture

A

Serrated polyps (including hyperplastic polyps)

53
Q

Type of non neoplastic polyps that has no clinical significance…

Includes hamartomas… which are?

A

Mucosal non-neoplastic

Hamartomas = benign tumor-like malformations made up of an abnormal mixture of cells/tissues

54
Q

Create polypoid appearance of overlying mucosa

A

Submuscosal lesions

55
Q

Bad to see on pathology report?

A

adenoma

dysplasia

(hyperplastic, not so bad)

56
Q

Inherited disorder

Development of 100s+ of polyps

Develop polypls by 15

Development of cancer is inevitable (requires an eventual total colectomy)

ANnual colonoscopy requiered until colectomy

A

Familial Adenomatous Polyposis

57
Q

Polyposis syndrome that presents w/ hamartomas and oral lesions

A

Peutz Jeghers Syndrome

58
Q

Familial Juvenile Polyposis

A

type of hamartomatous Polyposis syndrome

increased risk of colon CA

59
Q

Cowden disease

A

type of hamartomatous Polyposis syndrome

60
Q

AKA Lynch Syndrome

Autosomal dominant condition

Increased risk of abdominal organ cancer

Use what for screening?

A

Hereditary Nonpolyposis Colon Cancer (HNPCC)

Bethesda Criteria

61
Q

Colorectal cancer risks?

A

IBD

Smoking

Family Hx (first degree relatives)

Age (risk > after 45)

DIet high in fat and red meat

62
Q

Cancer lesions maybe present for years before symptoms begin. So?

A

We implement prevention and detection tests

63
Q

Colorectal CA prevention tests?

A

Colonoscopy

Flex Sig

CT colonography

64
Q

Colorectal CA DETECTION tests?

A

Fecal Immunochemical Test

Hemoccult SENSA

Fecal DNA

65
Q

What constitutes a high risk CRC pt?

A

Single first degree relative w/ CRC or advanced adenoma diagnosed at age > 60

Two first degree relatives w/ CRC adenomas

66
Q

What is the recommended screening for high risk patients?

A

Colonoscopy every 5 years beginning at age 40 years or 10 years younger than age at diagnosis of the youngest affected relative

67
Q

Used for prognosis AFTER diagnosis

(NOT a screening test)

USed as a marker for recurrence

A

Carcinoembryonic Antigen (CEA)

68
Q

Colorectal cancer of the right colon… ssx?

A

Iron deficiency anemia

Weakness/fatigue

69
Q

CRC of the L colon… ssx?

A

Change in bowel habits

Blood streaked stool

Obstructive symptoms

70
Q

CRC in the rectum… ssx?

A

Tenesmus

Hematochezia

Urgency

Decrease in caliber of stool (“ribbon stool”)

71
Q

What are the signs of advanced CRC?

A

Complete obstruction (“apple core” lesion)

Wt loss

Fever, chills, night sweat

72
Q

Work up for CRC?

A

FOBT (guiac or FIT)
CBC
CMP
UA

Colonscopy

73
Q

Tx for CRC?

A

Surgical resection (full/partial colectomy)
Chemotherapy
Radiotherapy

74
Q

CRC prognosis?

A

Stage 1 = best

Stage 4 = worst

GI block 2 (10 decks)

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